RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04330
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Machinist Mate, medically separated for “knee pain,” with a disability rating of 10%.  

CI CONTENTION:  “Please consider all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20041123	VARD -20050518	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Knee Pain	5099-5003	10%	Chondromalacia Patella Right Knee, s/p Arthroscopic Surgery	5099-5024	10%	20050421	
Unspecified Internal Derangement of the Knee	Cat II	Chondromalacia Patella Left Knee	5099-5024	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  According to service treatment records (STR), the CI reported bilateral knee pain with the right initially worse than the left.  Surgery was performed on the right knee only; however, at orthopedic follow-up visits, the CI reported bilateral knee pain, left worse than right and was diagnosed with bilateral patellofemoral syndrome (PFS).  Orthopedic notes indicated the CI was referred to the PEB due to the bilateral knee pain; therefore, the Board concluded that the knee conditions were bundled and rated as a single unfitting condition.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability. When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left knee conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Knee Pain.  According to the STR and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a history of bilateral knee pain and underwent a right knee arthroscopy with debridement and plica (inflamed joint tissue) excision on 15 April 2004.   No other abnormalities of the knee joint were noted during the procedure.  Following surgery, the CI reported bilateral knee pain, left greater than right and was diagnosed with bilateral PFS by an orthopedist.  Despite treatment, the right and left knee conditions could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “knee pain” and “unspecified internal derangement of knee” for PEB adjudication.  

At the MEB examination dated 7 September 2004, 5  months prior to separation, the CI reported patellar pain/tenderness and an inability to run, climb up and down ladders or walk for long distances.  The examiner reported “essentially normal” findings without specifying right, left or both knees.  The CI had a normal gait and there was no effusion or joint line tenderness.  “Mild to minimal” tenderness to palpation about the patella was documented as well as “mild” abnormal patellar tracking.  There was no crepitus or instability and patellar compression testing was negative.  Recorded range of motion (ROM) was 0 degrees (normal) of extension and 130 degrees (normal 140) of flexion.  

At the VA Compensation and Pension (C&P) evaluation in April 2005, 3 months after separation, the CI reported bilateral knee pain that was aggravated by prolonged walking, climbing stairs, running and jogging.  Physical examination was recorded separately for the right and left knees, but both were identical.  There was no tenderness, swelling, deformity, or instability of the right or left knee.  Right and left knee ROM was extension 0 degrees and flexion 135 degrees with crepitus noted on right knee ROM only.  There was no painful motion or additional loss of ROM with repetition.  Bilateral knee X-rays showed chondromalacia of both knees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a single 10% rating, coded 5099-5003 (analogous to arthritis, degenerative).  The VA assigned a 10% rating for the right knee and a 10% rating for the left knee, both coded 5099- 5024 (analogous to tenosynovitis) based on the VA C&P examination 3 months after separation, citing mild limited motion with crepitus on motion.  The Board first considered if both knees remained unfitting when separated from the PEB’s combined rating as elaborated above.  Orthopedic treatment records indicated the CI was referred to the PEB for bilateral knee pain due to recalcitrant PFS and a 24 June 2004 limited duty (LIMDU) board report noted limitations due to bilateral PFS.  The Board concluded that there was not a preponderance of evidence that overcame the Board’s presumption that each knee condition is reasonably considered separately unfitting.  Rating and coding rating criteria for the right and left knees are identical as documented at the MEB NARSUM and VA C&P examinations; therefore the ratings for the knee conditions are considered together.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) for either knee.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes for either knee, and there was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  

Crepitus of the right knee was noted at the VA C&P examination but painful motion was not documented for either knee during this evaluation or in the MEB NARSUM.  Therefore, a 10% rating could be supported for the right knee (based on §4.59, §4.40 and §4.45), but not the left knee.  The Board considered a bilateral rating of 10%, coded 5099-5003 (analogous to degenerative arthritis), which is compatible with both the pathology and disability for PFS of two major joints.  There was no evidence of occasional incapacitating episodes of the knees to warrant a 20% rating under the 5003 code.  After deliberations, the Board found that despite unbundling the knees there was no higher combined rating supported (for either or both knees together) than the 10% adjudicated by the PEB and therefore no change to the PEB adjudication is recommended because there is no benefit to the CI.  The Navy PEB also listed “unspecified internal derangement of the knee” as a related Category II condition (contributes to the primary unfitting condition but not separately ratable).  The impairment from the Category II condition was properly subsumed under the overall rating for the knee pain condition IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the knee pain condition.

BOARD FINDINGS:  In the matter of the knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141125, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 10 Jun 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC